Disclaimers
Tribute® HMO SNP Disclaimers
A health plan with a Medicare contract.
Tribute® HMO SNP is offered by the following organization that contracts with the Federal government: SelectCare of Oklahoma, Inc., a member of the Universal American family of companies.
You must continue to pay your Medicare Part B premium. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, 2013. Limitations, copayments and restrictions may apply. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan.
Low Income Subsidy (LIS)
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
- Your State Medicaid Office.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
Exceptions, Appeals and Grievances
An exception is a type of initial determination (also called a coverage determination) involving a Part D drug. A plan member or their doctor may ask us to make an exception to our Part D coverage rules in a number of situations.
Tribute allows members to submit complaints to the plan which may become either an Appeal or Grievance.
Enrollment Limitations
You must have Part A and Part B to enroll in the plan. Members may enroll only during specific times of the year. Contact a Member Advocate at 1-800-817-3515, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week, to obtain more information.
Pharmacy Network
We have formed a network of pharmacies. To receive plan prescription drug benefits, you must use a network pharmacy, except in non-routine circumstances, and quantity limitations and restrictions may apply.
Access Information
You must receive all routine care from plan providers. You must use plan providers except in emergency or urgent care situations. If you obtain routine care from out-of-network providers neither Original Medicare nor Tribute will be responsible for the costs.
Availability of Alternate Formats
This information is available for free in other languages. Please contact our Customer Service number at 1-800-817-3515, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week for additional information.
This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-English language. For additional information, call customer service at the phone number listed above.
Esta información está disponible sin cargo en otros idiomas. Para obtener más información, comuníquese con el Servicio de Atención al Cliente al número 1-800-817-3515, de 8:00 a.m. a 8:00 p.m. en su zona horaria local (los usuarios de TTY deben llamar al 1-800-958-2692) los 7 días de la semana.
Este documento puede estar disponible en otros formatos, como Braille, letra grande o otros formatos alternativos. Este documento puede ser disponible en un idioma no inglés. Para obtener más información, llame al servicio al cliente en el número de teléfono que aparece arriba.
Conditions Associated with Receipt or Use of Benefits
Using our
Plan Finder, you can view a description of conditions associated with receipt or use of Tribute benefits.